Insulin infusion device complication

Background

InsulinPumpALIEM.jpg
  • Commonly used by patients with type 1 diabetes in the US
  • External device connected by flexible tubing to a subcutaneous catheter
  • Delivers continuous basal insulin and (by manually activating) bolus insulin (prandial or correction doses)
  • Patient switches subcutaneous site every 3 days, refills insulin reservoir as needed every few days

Complications

  • Hyperglycemia/DKA
    • Due to failure to deliver insulin
    • accidental (or iatrogenic) disconnection, kinked tubing, empty reservoir, uncharged batteries, poorly positioned needle, lipohypertrophy, patient not rotating sites
    • DKA can occur very rapidly if pump fails, since pumps only use rapid-acting insulin
  • Hypoglycemia
  • Local complications
    • Cellulitis[1], usually due to strep or staph
    • Local reactions to adhesives or insulin preparation
    • Lipohypertrophy
      • Subcutaneous granulation tissue due to local insulin action
      • May look/feel like an abscess
      • Area has decreased sensation
      • Infusing through such sites→ erratic insulin absorption→ labile blood glucose, hyperglycemia

Evaluation

  • See Hyperglycemia and DKA
  • See Hypoglycemia
  • See Cellulitis
  • Patients most often know how to operate and perform basic diagnostics on their pump
  • Many devices have a log of bolus histories and changes to basal rates, alarms, etc.
  • All major pump manufacturers have a 24/7 technical support hotline

Management

  • Awake, alert patients without diabetes-related complaints should be allowed to operate their pump while in the ED
  • If pump needs to be disconnected for >1hr, give a dose of subcutaneous insulin
  • Hypoglycemia
    • Do NOT disconnect pump
    • Work up and treat as you would any other hypoglycemic patient
  • Hyperglycemia
    • Have patient administer an insulin bolus
  • DKA
    • Assume device failure
    • Turn off and disconnect pump by pulling the catheter out from under the dressing removing it from the subcutaneous insertion site
    • Continue usual DKA management

Disposition

See Also

External Links

References

  1. Richardson T, Kerr D. Skin-Related Complications of Insulin Therapy: Epidemiology and Emerging Management Strategies. Am J Clin Dermatol, 2003; 4 (10): 661-667